title: Fractionated high dose rate intraluminal brachytherapy in palliation of advanced esophageal cancer.
abstract: OBJECTIVE
  To optimize the dose of fractionated brachytherapy for palliation of advanced esophageal cancer.
  
  
  METHODS
  One hundred and seventy-two patients with advanced esophageal cancer were randomized to receive 12 Gy/2 fractions (group A); 16 Gy/2 fractions (group B), and 18 Gy/3 fractions (group C) by high dose rate intraluminal brachytherapy (HDRILBT). Treatment was given weekly and dose prescribed at 1 cm from the source axis. Patients were followed up monthly and assessed for dysphagia relief and development of complications.
  
  
  RESULTS
  Twenty-two patients died before completing treatment due to advanced disease and poor general condition. The overall survival was 19.4% at the end of 12 months for the whole group (A--9.8%, B--22.46%, C--35.32%; p > 0.05). The dysphagia-free survival was 28.9% at 12 months for the whole group (A--10.8%, B--25.43%, C--38.95%; p > 0.05). Forty-three patients developed fibrotic strictures needing dilatation (A--5 of 35, B--15 of 60, C--23 of 55; p = 0.032). Twenty-seven patients had persistent luminal disease (A--11, B--6, C--10), 15 of which progressed to fistulae (A--7, B--2, C--6; p = 0.032). There was no effect of age, sex, race, histology, performance status, previous dilation, presenting dysphagia score, presenting weight, grade, tumor length, and stage on overall survival, dysphagia-free, and complication-free survival (p > 0.05). On a multivariate analysis, brachytherapy dose (p = 0.002) and tumor length (p = 0.0209) were found to have a significant effect on overall survival; brachytherapy dose was the only factor that had an impact on local tumor control (p = 0.0005), while tumor length was the only factor that had an effect on dysphagia-free survival (p = 0.0475). When compared to other forms of palliation currently available (bypass surgery, laser, chemotherapy, intubation, external radiotherapy), fractionated brachytherapy gave the best results with a median survival of 6.2 months.
  
  
  CONCLUSIONS
  Fractionated brachytherapy is the best modality for palliation of advanced esophageal cancer. It offers the best palliation to patient when compared to all other modalities currently available. The optimal brachytherapy dose ranges between 16 Gy in two fractions and 18 Gy in three fractions given a week apart.
authors.affiliation: Department of Radiation Oncology, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: R K
authors.initials: RK
authors.lastname: Sur
authors.forename: B
authors.initials: B
authors.lastname: Donde
authors.forename: V C
authors.initials: VC
authors.lastname: Levin
authors.forename: A
authors.initials: A
authors.lastname: Mannell
mesh_terms: D001918:Brachytherapy / Q000009:adverse effects / Q000379:methods*; D003680:Deglutition Disorders / Q000209:etiology; D018572:Disease-Free Survival; D019583:Dose Fractionation, Radiation; D004938:Esophageal Neoplasms / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010166:Palliative Care / Q000379:methods*; D011446:Prospective Studies; D017211:Treatment Failure